16 osgood schlatter, kienbock, sever, koher
DESCRIPTION
Enfermedad de Osgood Shclatter y otras necrosis avascular.TRANSCRIPT
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Necrosis Avascular
Enfermedad de Osgood Schlatter
Definicin
Fenmeno de traccin resultante de contraccin repetitiva del cudriceps a travs del tendn rotuliano en su insercin en el tubrculo tibial inmaduro.
Causa principal de dolor de rodilla: 8 a 15 aos
Autolimitante
Etiologa / Factores de Riesgo
Contraccin repetida que causa avulsiones parciales o micro avulsiones del tejido condrofibroso del tubrculo tibial anterior
Deporte:
Atletismo, gimnasia, futbol, etc.
Edad: 8 a 15
Sexo masculino (3:1)
Crecimiento seo rpido
Saltos repetitivos (deporte)
The proximal area of the patellar tendon insertion separates, resulting in elevation of the tibial tubercle. During the reparative phase of this stress fracture, new bone is laid down in the avulsion space, which may result in a deviated and prominent tibial tubercle. When an individual with an injured tibial tubercle continues to participate in sports, more and more microavulsions develop, and the reparative process may result in a markedly pronounced prominence of the tubercle, with longer-term cosmetic and functional implications. A separated fragment may develop at the patellar tendon insertion and may lead to chronic, nonunion-type pain.
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Epidemiologia
Incidencia:
5% de adolescentes NO ACTIVOS
20% de adolescentes Atletas
25 a 50% de los casos son bilaterales
Clinica
Evolucin prolongada
Tumoracin subcutnea en la regin del tubrculo tibial
Dolorosa a la palpacin
Dolor de Rodilla
Exacerba con actividad fsica
Bajar y subir escaleras
Arrodillarse
Inflamacin moderada
Mas aumento de sensibilidad por debajo de la patella.
Other physical examination findings may include the following:
Proximal tibial swelling and tenderness
Enlargement or prominence of the tibial tubercle
Reproducible and aggravated pain by direct pressure and jumping (quadriceps contraction)
Pain with resisted knee extension (quadriceps contraction)
Full range of motion of the knee
Hamstring tightness
No effusion or meniscal signs
Negative Lachman test (no knee instability)
Normal neurovascular examination
No abnormal findings in the hip and ankle joints
Tenderness to palpation over the proximal tibial tuberosity at the site of patellar insertion may be present. A firm mass may be palpable.
Erythema of the tibial tuberosity may be present.
Some patients may have quadriceps atrophy.
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Diagnostico
Radiografa lateral de rodilla
knee in slight internal rotation of 10-20.
However, plain films are helpful for ruling out other etiologies, such as neoplasm, acute tibial apophyseal fracture, and infection. In addition, radiographs may indicate:
Superficial ossicle in the patellar tendon
Irregular ossification of the proximal tibial tuberosity
Calcification within the patellar tendon
Thickening of the patellar tendon
Soft-tissue edema proximal to the tibial tuberosity
In severe cases, radiographs may reveal radiodense fragments or ossicles separated from the tibial tuberosity.
Occasionally, the radiographs may reveal irregularity, fragmentation (seen below), or increased density of the ossification of the tibial tubercle. This pattern may be a normal variant in asymptomatic children.
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Tratamiento
Conservador: hielo por 20 mins cada 2-4 horas
Analgsico + AINE
Disminucin de activades exacerbantes
Inmovilizador de rodilla
No se recomiendan esteroides
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Pronostico
Excelente
10% pueden persistir sntomas hasta la adultez.
Falta de apego al tratamiento
OSD usually resolves by the time the patient is aged 18 years, when the tibial tubercle apophysis ossifies.
In some cases, however, discomfort may persist for 2-3 years until the tibial growth plate closes.
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Enfermedad de Kienbck
Necrosis avascular del hueso semilunar
Etiologa desconocida
Secundario a osteonecrosis
Frecuente en adultos (varones) de 20 a 40 aos de edad
Cargas repetitivas en mueca
who is either a manual laborer or one who participates in recreational activities that repetitively load the wrist.
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Clinica
Dolor de mueca (dorsal)
Disminucion de arco de movimiento
Pobre agarre
Inflamacion y sensibilidad de la articulacion radiocubital inferior
Masculino de 20 a
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Diagnostico
Radiografia
Tratamiento
Inmobilizacion
AINE
Quirurgico
Excision de semilunar con o sin reemplazo
Procedimientos para nivelar la articulacion
Fusion intercarpal
revasvularizacion
Etapas
I: radiografa normal
II: Aumento de radiodensidad del semilunar con posible decremento de la altura radial del mismo hueso
Stage I - Normal radiograph
Stage II - Increased radiodensity of lunate with possible decrease of lunate height on radial side only
During the first stage of the disease, the symptoms are similar to those of a wrist sprain. Although the blood supply to the lunate has been disrupted, x-rays may still appear normal or suggest a possible fracture. An MRI scan can better detect blood flow and is helpful in making the diagnosis in this early stage.
An x-ray of a patient's wrist during Stage I shows no deterioration of the lunate bone.
The lunate bone begins to harden due to the lack of blood supply during Stage 2. This hardening process is called sclerosis. In addition, the lunate will appear brighter or whiter in areas on x-rays, which indicates that the bone is dying. To better assess the condition of the lunate, your doctor may also order either MRI scans or computed tomography (CT) scans.
The most common symptoms during this stage are wrist pain, swelling, and tenderness.
(Left)This illustration shows that the lunate has hardened with more than one fracture line.(Right)The lunate is brighter than the surrounding bones, which indicates that the bone is dying.
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III: Colapso del semilunar
A: sin rotacin escafoidea
B: rotacin escafoidea
IV: cambios degenerativos alrededor del semilunar
Stage IIIa - Lunate collapse, no scaphoid rotation
Stage IIIb - Lunate collapse, fixed scaphoid rotation
Stage IV - Degenerative changes around the lunate
3: the dead lunate bone begins to collapse and break into pieces. As the bone begins to break apart, the surrounding bones may begin to shift position.
During this stage, patients typically experience increasing pain, weakness in gripping, and limited wrist motion.
Both the illustration and x-ray image show that the lunate has begun to collapse and several bones in the wrist have shifted out of position.
4: the surfaces of the bones surrounding the lunate also deteriorate, and the wrist may become arthritic.
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Enfermedad de Sever
Necrosis avascular de calcaneo
Inflamacion apofisiaria de calcaneo
Etiologa: trauma repetitivo
Mas frecuente en varores de 10 a 12 aos
Deportistas
La aposifisis de calcaneo se solidifica en kids de 9 a 10 anhos (empieza) y se termina a los 17, en ninhas poco antes.
Se cree que ocurren microfracturas por estres repetido
Clinica: dolor progresivo de talon, con exacervacion a la actividad fisica.
A la dorsiflexion forzada de tobillo hay molestia
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Diagnostico
Clinico
Diagnostico: clinico, se usa la placa para descartar otras anomalias
MRI para descartar osteomielitis
Radiographic findings include increased sclerosis and fragmentation of the calcaneal apophysis NO ESPECIFICOS
primary value in this setting is for exclusion of other causes of heel pain. This point should be clearly explained to patients and parents.
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Tratamiento
Reducir actividad fisica
Ejercicios de calentamiento adecuados
AINE
Ibuprofeno
Naproxeno
Enfermedad de Kohler
Necrosis avascular del hueso navicular
5 a 10 aos de edad. Mas frecuente en varores
Marcha antialgica, sensibilidad en la parte media del pie
Incidente vascular o trauma.
The navicula is the last tarsal bone to ossify in children. This bone might be compressed between the already ossified talus and the cuneiforms when the child becomes heavier. Compression involves the vessels in central spongy bone, leading to ischemia, which then causes clinical symptoms. Thereafter, the perichondral ring of vessels sends the blood supply, allowing rapid revascularization and formation of new bone. The radial arrangement of the vessels of this bone is of great importance in explaining why the prognosis of this lesion is always excellent.
Cargar peso lateralmente.
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Diagnostico
Clnico
increased radiodensity of the navicular with a flattened appearance to the ossific nucleus
Radiography is indicated (see the first image below). The lateral view shows a flat tarsal scaphoid (see the second image below). The space between the talus and the cuneiforms is not decreased. Frequently, there is an irregular ossification of the tarsal navicular bone or radiologic changes that resemble Khler disease, but the diagnosis must not be made in the absence of clinical signs.
If pain persists 6 months after casting, magnetic resonance imaging (MRI) or computed tomography (CT) is necessary to exclude a tarsal coalition
Furthermore they revealed increased density and callus formation in the proximal 1st through 4th metatarsals. This was consistent with multiple non-displaced fractures of the proximal metatarsals secondary to trauma
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Tratamiento
Uso de frula por debajo de rodilla
En ligero varo
weightbearing below-the-knee cast is recommended
in moderate varus (10-15)
In this position, the navicula is relaxed from posterior tibialis strain.
Arch supports can be prescribed after the cast period and used for an average of 6 months. In mild cases, soft arch supports may be the only treatment necessary.
Dolor debe desaparecer en 3 meses, la ferula puede ser 6 semanas, sino, otra por 6 semanas. Si persiste buscar coalicion tarsal o un navicular accesorio.
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